NCHC | Facts About Healthcare - Health Insurance Quality

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Health Care Quality

Facts On The Quality Of Health Care

Introduction

The United States spends the most money on medical care of all advanced industrialized countries, but it performs more poorly than most on many measures of health care quality.^{1, 2, 3, 4} There are widespread problems with the quality of much of America's health care. Eliminating variations in the delivery of evidence-based care across the health care system could save up to 88,000 lives each year.5 Billions of dollars in lost productivity and in hospital costs could be averted through more consistent delivery of evidence-based best practices in medical services and administrative practices.⁵

Although nearly $2.4 trillion a year is spent on medical care, many people are receiving more care than they need, many are receiving less than they need, and many are receiving the wrong kind of care. In addition, preventable and harmful errors are occurring frequently. Millions of Americans are injured and tens of thousands die unnecessarily each year because of medical errors. Moreover, these problems are not recognized or addressed adequately by the government or those who deliver care.

The type of medical services a patient receives often depends on whether the patient has health insurance. The second most significant factor is where the patient is treated. And quality does not consist of consumers being able to see the provider of their choice, or when and where they want to see them. Quality is receiving the right care, in the right setting, at the right time.

SIGNIFICANT HEALTH CARE QUALITY PROBLEMS PERSIST

The U.S. is 33 percent worse than the best country on mortality from conditions amenable to health care – that is, deaths that could have been prevented with timely and effective care.⁴
The infant mortality rate in the U.S. is 7.0 deaths per 1,000 live births, compared with 2.7 in the top three countries.⁴
Recent studies show that only a little more one-half (54.9 percent) of adult patients receive recommended care. The level of performance is similar whether it is for chronic, acute, or preventive care and across all spectrums of medical care -- screening, diagnosis, treatment, and follow-up.⁶
Underuse of care is sometimes a greater problem than overuse. Patients do not receive recommended care (as prescribed in national medical specialty guidelines) about 46 percent of the time. Another 11 percent of patients receive care that is not recommended and potentially harmful, according to practice guidelines.⁶
The 30 percent of sick Americans report that their doctor did not review or discuss all of the medications they had taken in the last two years.⁷
Quality of care varies considerably by medical condition. People with cataracts receive about 79 percent of recommended care. Patients with alcohol dependence receive only about 11 percent of recommended care.⁶
People with diabetes receive only 45 percent of the care they need. Fewer than half of patients with diabetes have their blood sugar levels measured on a regular basis.⁶
Nearly one-third (32 percent) of patients with coronary artery disease receive recommended care, and less than one-half (45 percent) of patients who suffer a heart attack receive medications that could reduce their risk of death by more than 20 percent.⁶
Evidence-based medical care indicates that when a patient has a heart attack, the likelihood of that person’s dying from a second heart attack can be reduced by over 40 percent through the use of beta blockers. Over 40 percent of patients do not receive this treatment -- the noncompliance rate puts 450,000 Americans at substantially higher risk every day.⁷
Less than two-fifths (39 percent) of patients with pneumonia receive recommended care. Only 65 percent of older adults are vaccinated against pneumonia. Nearly 10,000 deaths from pneumonia could be prevented each year through regular vaccinations.⁶
Patients with colorectal cancer receive only one-half (54 percent) of recommended care. Less than two-fifths of adults are screened for colorectal cancer. According to studies, nearly 10,000 deaths could be prevented each year through routine screening and follow-up care.⁶
Patients with hypertension receive less than two-thirds of recommended care. Poor control of high blood pressure results in nearly 70,000 preventable deaths each year.⁶
Twenty-two percent of sick adults in America were sent for duplicate tests by different health care professionals between 2003 and 2004.⁸
Despite recent gains, more than 100 million insured Americans do not enjoy the improved care that results from the use of quality measures and reporting.⁵

HIGH ERROR RATES LEAD TO DEATHS AND INJURIES

General Medical Errors

The Institute of Medicine estimates that nearly 100,000 patients die in hospitals each year due to medical errors.⁹ This is three times the number who die on the highways. This number does not include deaths that occur in the ambulatory setting or deaths after discharge that resulted from medical errors when the patient was hospitalized.

HealthGrades, an organization that publishes rankings of hospitals and physicians, reported in a recent study that there were 238,000 potentially preventable deaths between 2005 through 2007 – just for the Medicare population.10 Nearly 50 percent of preventable deaths were associated with four diagnoses–heart failure, community-acquired pneumonia, sepsis and respiratory failure.
Patient safety incidents in American hospitals grew from 1.18 million to 1.24 million among the 40 million hospitalizations covered under the Medicare program, and incidents varied widely from state to state, and among the best and worst hospitals.¹⁰
Total national costs (lost income, lost household functioning, disability and health care costs) of preventable adverse events (medical errors resulting in injury) are estimated to be $35 billion a year.⁹
Medication errors alone, occurring in or out of the hospital, are estimated to account for over 7,000 deaths annually. This represents about 16 percent more deaths than the number attributable to work-related injuries.⁹
In a recent study of wrong-site surgery cases, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) cited several factors contributing to medical errors: the involvement of multiple surgeons, performance of several different procedures during one surgery, and pressure from hospital administrators to finish the surgery quickly.¹¹
The Harvard Medical Practice Study reported that four percent of hospitalized patients suffered an injury due to treatment and that two-thirds of these were caused by errors. Extrapolating to the nation as a whole, it was estimated that approximately one million Americans are injured by errors in treatment in hospitals each year (Lucian Leape, Harvard School of Public Health).
In a recent survey, one-third of U.S. patients reported a medical, medication or laboratory error in the past two years.⁴
According to The Leapfrog Group, an organization of businesses that support quality improvement initiatives, over 90 percent of hospitals have not implemented computer physician order entry programs (doctors enter patient prescriptions and other orders into computers linked to error prevention software) to standards set by Leapfrog.¹²
Nine in ten hospitals fail to meet the standards for performing two-high risk procedures: coronary artery bypass graft surgery and abdominal aortic aneurysm repair.¹²
Among adults in seven countries surveyed by the Commonwealth Fund, adults in the United States reported the highest overall error rates, including laboratory and medication errors. One third of U.S. adults with chronic conditions reported a medical, medication, or lab test error in the past two years.¹³

Hospital Acquired Infections

Preventable infections acquired in hospitals cost $4.5 billion per year and contribute to more than 88,000 deaths–one death every 6 minutes in the U.S.¹⁴
There are over 250,000 hospital-acquired pneumonia cases and 23,000 related deaths in the U.S. every year.¹⁵
According to the Centers for Disease Control (CDC), there are over 80,000 infections caused when an IV tube that contains bacteria is inserted into a large vein and infects the patient’s bloodstream. These are also called “central line infections,” and they cost the nation up to $2.3 billion and result in 20,000 deaths per year in intensive care units in the U.S.¹⁶
Pneumonias caused by bacteria from ventilators cost the nation over $1.5 billion and account for 1.75 million additional hospital days a year.¹⁷
According to a 2003 study published in the New England Journal of Medicine, the number of reported bloodstream infections related to catheters that occur in hospitals has almost tripled since 1975.18 In a related study published in the Annals of Internal Medicine, researchers found that physicians wash their hands only 57 percent of the time.¹⁹

Need for System Improvements to Improve Quality

Among six nations studied by the Commonwealth Fund in a recent report on quality of care performance measures–the U.S. ranked last. Most troubling is that the U.S. fails to achieve better health outcomes than the other countries, and is last on dimensions of access, patient safety and efficiency. The United States compared to other nation’s health care systems scores particularly low on chronic care management and safe, coordinated care and patient-centered care pull its overall scores down significantly.¹⁸

Experts in the field of quality assurance believe that the American health care delivery system is in need of fundamental change in order to achieve major improvements in health care quality. They stress that the current care systems cannot do the job.

Key challenges include:

Redesigning care processes based on best practices;
Using evidence-based medicine to improve clinical practice;
Using information technologies to improve access to clinical information and support clinical decision making;
Coordinating care across patient conditions, services, and settings over time, and
Incorporating performance and outcome measurements for improvement and accountability.

It is time for our nation and its leaders to devote themselves to achieving for the public the necessary improvements in performance -- error reduction, patient safety, identification of what works best in medical care, service enhancements, and waste reduction -- which will enable Americans to have the care they deserve at a cost they can afford.

Notes

Keehan, S. et al. “Health Spending Projections Through 2017, Health Affairs Web Exclusive W146: 21 February 2008.
Blendon, R.J., C. Schoen, C.M. DesRoches, R. Osborn, K. Zapert, E. Raleigh, “Confronting Competing Demands to Improve Quality,” Health Affairs, 2004:23(3): 119-135.
Schoen, et al., “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” Health Affairs Web Exclusive W5-509, 03 November 2005.
The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006.
National Committee for Quality Assurance. The State of Health Care Quality, 2008, Industry Trends and Analysis. Washington, DC, 2007. The State of Health Care Quality 2008 is available to the public on NCQA’s Web site, http://www.ncqa.org/sohc Much of the data from the report is used in NCQA’s new Health Plan Report Card, which allows consumers to compare health plans based on NCQA Accreditation results and HEDIS quality scores. To see the new Health Plan Report Card, log on to http://reportcard.ncqa.org
McGlynn, E.A., et al, “The Quality of Health Care Delivered in the United States,” The New England Journal of Medicine, 2003:348(26): 2635-2645; and updated in Asch, S., et al., “Who is at Greatest Risk for Receiving Poor-Quality Health Care? The New England Journal of Medicine, 2006:354(11): 1147-1156.
American Heart Association, Heart Attacks and Angina Statistic,” 2002. http://www.americanheart.org/Heart_and_Stroke_A__ZGuide/has.html
Davis, K., et al, “Mirror, Mirror on the Wall: Looking at the Quality of American Health Care Through the Patient’s Lens,” The Commonwealth Fund, January 2004.
Corrigan, J.; L. Kohn, M. Donaldson, eds. To Err is Human: Building a Safer Health System. Committee on Quality of Health Care in America, Institute of Medicine, The National Academies Press, 1999.
HealthGrades, The 11th Annual Health Grades Hospital Quality in America Study, HealthGrades Inc., Golden, CO, 2008.
Joint Commission on Accreditation of Health Care Organizations. Sentinel Event Alert, 05 December 2001.
The Leapfrog Group. Hospital and Quality Safety Survey, October 2006.
The Commonwealth Fund. Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007. November 2007.
Weinstein, R.A. Nosocomial Infection Update. Special Issue. Emerging Infectious Diseases. Vol 4 No. 3, July-Sept 1998.
Wiblin, R. Nosocomial Pneumonia. In: Prevention and Control of Nosomial Infections, Wenzel, R. (Ed), Williams and Wilkins, Baltimore 1997, 807.
Centers for Disease Control, Guidelines for the Prevention of Catheter Related Infections, August 2002.
Dodek, P., S. Keenan, D. Cook, et al, Evidence-based Clinical Practice Guideline for the Prevention of Ventilator-associated Pneumonia, Annals of Internal Medicine 2004; 141:305.
McGee, D.C. and M.K. Gould, “Preventing Complications of Central Venous Catheterizations, The New England Journal of Medicine, 2003, 348:1123-1133, March 20, 2003.
Pittet, D, et al, “Hand-Washing Practices and Beliefs of Physicians,” Annals of Internal Medicine, 2004, 141:1, 1-38, July 6, 2004.
Davis, K, et al. Mirror, Mirror on the Wall: An international Update on the Comparative Performance of American Health Care. The Commonwealth Fund, May 15, 2007